His antics have certainly prompted speculation about his sanity in the public and media. Over the past year, the physician community–and particularly the psychiatric community– has also been weighing in, in defiance of the “Goldwater” rule. And that concerns me deeply.

Section 7.3 of the American Psychiatric Association Principles of Medical Ethics—Goldwater’s formal name—states that it is unethical for a psychiatrist to publicly offer a professional opinion on the mental health of an individual if they have not formally examined that person and received consent to release their impressions. The rule is named after Barry Goldwater, who successfully sued Fact magazine for defamation after it published a poll of 1,189 psychiatrists suggesting Goldwater was unfit to be president of the U.S. ahead of his 1964 run. (In Canada, the Canadian Psychiatric Association provides similar advice in a position statement on courtroom testimony: “Whenever possible, psychiatrists should testify… as to the mental state of a particular person only if they have examined that person or made significant attempts to do so.”)

But since Trump has taken office, certain quarters of the American psychiatric community have been arguing that a “moral duty to warn” should override Goldwater. This past fall, a movement of mental health professionals formed with the goal of removing Trump from office under the U.S. Constitution’s 25th Amendment, on the basis that he is “psychologically unfit to serve.” A subsequent book has attracted much attention, both in popular media and academically, notably in a New England Journal of Medicine op-ed which argues that “standards of professional ethics and professionalism change with time and circumstance.” Their message is clear: Unusual times require physicians to speak up in defiance of Goldwater.

For my part, I’m no fan of Trump and find many of the things he says abhorrent and disconcerting. But is that really a justification for offering a sidewalk diagnosis?

A public health perspective

My support for Goldwater is based on three pillars. First, while it might seem that the rule arose in response to a lawsuit, it’s a good reminder of the principle of “no examination, no diagnosis,” which is not unique to psychiatry but fundamental to medical practice and the sanctity of the doctor-patient relationship. This principle dictates why one cannot ethically treat family members (because one can’t objectively examine them) and also why transport regulators across North America require that reports of a patient being medically unfit to drive be based on formal examinations as opposed to what the doc might have seen on the drive home.

Second, choosing to ignore the Goldwater rule in this one instance invites the question: Why not others? Indeed, it could be argued that the mental health of many politicians, both current and historic, might warrant public scrutiny and even intervention. Consider alternate realities where public psychiatric discourse might have forced JFK out of office due to sex addiction, or Lincoln due to severe depression, or Churchill—in the middle of the war effort—for supposed bipolar disorder. Allowing psychiatrists to present such opinions about political leaders sans exam turns medical expertise into a political lever, one that could potentially create chaos and threaten peace, order, and good government. Not to mention that the decision to selectively overturn Goldwater could fuel perceptions of psychiatrists and the entire medical community as being partisan.

Which leads to my third reason for supporting the Goldwater rule. As a public health physician, my work aims to protect, promote, and optimize the health of the community through population-level interventions. These efforts require me to be seen as objective and impartial, providing recommendations that are based on data and evidence. Attempts by my psychiatric colleagues to offer professional opinions about the mental health of a public figure that they have not examined undermine public health’s efforts to stand objectively against poor policy and programming decisions.

We’re all in this together

Recently, I raised my concerns about ignoring Goldwater with a colleague in mental health. The colleague not only disagreed, but further suggested that I wasn’t in a position to call the matter into question, given that I am not trained and don’t practise in the field.

I couldn’t disagree more.

Fundamental standards exist across specialties. “No exam, no diagnosis” is one of these, and the Goldwater rule suggests that psychiatry is no exception. While psychiatrists are certainly the specialists, mental health considerations apply across specialties; family doctors likely diagnose mental illness more frequently than psychiatrists, and physicians of all stripes assess competence every single day. And it is important to remember that a mental illness diagnosis does not automatically signify incompetence. Individuals who experience mental illness may still be fully capable of making rational decisions.

Additionally, professional colleagues have a duty to question one another, especially where things are not clear-cut. If a family physician gets a referral back from a specialist that they don’t understand or agree with, they are within their rights to ask questions rather than tacitly accept direction. Psychiatrists would do well to remember that any dialogue around overturning Goldwater reflects on all physicians. For the populations I serve, and for all of us in the medical field, I feel I have a duty to question my colleagues around any position that might impact the standing of all physicians.

Dr. Lawrence Loh is a Toronto-based public health and preventive medicine physician who serves as adjunct professor at the Dalla Lana School of Public Health. This work represents his views and not those of the organization he is affiliated with.

Enter the debate: reply to an existing comment

14 comments

Aurelia CFebruary 1st, 2018 at 9:57 am

It’s important to keep that rule, because not everything is caused by an untreated mental health issue. Funny enough, some people and some politicians are just average everyday jerks. Being unkind, rude, and greedy are not mental illnesses.
In fact, most people with mental health conditions are much nicer than guys like Trump.

When will the DSM leave the public alone?
Everyone knows that not one person can escape a diagnosis and this includes psychiatrists.
But then, we knew all along that a preoccupation of watching and listening and judging, is monkey behavior. There is something compulsive in a person who at a young age preoccupies himself with watching and wanting the power to subject their belief about normalcy onto others.
Helping people and labeling are worlds apart. And there is absolutely no need to do both.
It is an absolutely defaming, inflaming, hurtful practice and equals to create environments that result in shunning innocent people. But so many want a diagnosis, on the belief that somewhere there is a normal, and are happy to live underneath that umbrella.
I think Trump is smart enough to never step into a Psychiatry office. After all, he was clever enough to know that the time was ripe for him. He’s a let’s see what happens if I roll this die, kind of guy 🙂
Like him or leave him, he is not a bit different in understanding, compassion etc than many who hold power over others. After all, power and meanness, often go hand in hand, often result from a dissastisfied childhood, where you were either bullied, sheltered or were the cat’s meow.

I agree with the principle of no formal psychiatric diagnosis without a formal psychiatric examination, but a formal diagnosis is not what the many professionals who have spoken out against Trump are offering. Warnings, based on the countless transcripts, audio and video recordings available for all to see do no constitute a formal psychiatric diagnosis, nor does the use of psychological terms which have entered the common vernacular, like narcissism, megalomania or pathological lying.

No member of society should be prevented from expressing their concerns about political leaders they view as profoundly incompetent and potentially dangerous. It would be folly to muzzle those members of society who by virtue of their training and professional experience are likely to be the most informed and articulate voices in the public space. In a time when we are awash in opinions of dubious veracity do we really want to filter out those that are likely to be the most accurate?

Thanks for your thoughts. I would perhaps respond by suggesting that it’s fine for anyone, doctors especially, to express concern. That’s our right enshrined in our fundamental freedoms.

Where the line becomes fuzzy is where we bolster our expressions of concern with expert insight – discussing behaviours, signs and symptoms, and leaving nothing to the imagination about where we would proceed if we were given the opportunity to formally assess. In seeing what certain quarters have put forward it’s disingenuous to say that isn’t formal diagnosis semantically because they aren’t writing “Dx: ____” at the end of their thoughts.

Simply put, once physicians start leveraging their expertise to add detail and colour to their commentary, they’ve crossed the line from simple expression of concern to providing expert opinion. Inferring or suggesting a diagnosis is as dangerous as formally making one.

With respect – there is a difference between expressing concern as a citizen as is one’s right, and expressing a professional opinion standing with your credential. No one is limiting the former and I myself above say that much of what Trump says is concerning.

The analogy would be the dreaded “is there a doctor aboard the plane?” Once you identify yourself as such, even if you don’t end up examinining the patient in question, your words and advice carry a different weight than if you were simplynthe sick passenger’s seatmate and simply sharing your concern incognito.

Donald Trump is no more or less crazy than any of the particular medical staff I have encountered at any of the downtown (Toronto) teaching hospitals (late 80’s to mid 2000’s). These ICU, CCU or CVICU senior attending clinicians each had their characteristic ‘big personalities’. We took instruction from them, verbal abuse from them and in fact, at times, praise from them. For example, on break we bitched and moaned about Dr. X and laughed at things Dr. Y said. Each of us had our opinions about these clinicians – some liked Dr. X and others disliked Dr. Y (and vise versa). We did not *hate* these staff clinicians nor did we think that they were crazy. American politics is extremely polarized now – and haters are always going to hate – and as evidence, this above opinionated article was constructed to proffer some rules on how to gently hate.

On the contrary, this article is calling for respect of professional standards and due process in respect of The Donald, suggesting that the decision of some physicians to publicly offer their expert opinions on Trump’s mental health is not in the interests of anyone.

Seems like you are gently hating on this article, as you have misunderstood the argument the writer poses. He simply argues that professionals need to refrain from giving a diagnosis without an appropriate consultation, let alone breaching patient privacy. Not sure what that has to do with the personalities of your seniors…

True, but mere opinion differs from a diagnosis. All medical professionals are allowed to have a public character that can post personal opinions. The risk of course, is that those who know you, or of your credentials, may fault you rightly or wrongly, for abusing the Goldwater rule. Speaking outside your field protects you somewhat. Note that there is a vast difference between saying “He has Narcissistic Personality Disorder”, and “In my unverified opinion, he may be exhibiting some symptoms of NPD.”

But is there really that vast of a difference? In both cases, you are providing an expert opinion. The insinuation in the latter statement is just as much based on your professional credentials and expertise than the former; the only difference is semantics, and the public does not know the difference other than an MD is saying so.

On US media, psychiatrists HAVE been brought on as EXPERT physicians to give their DIAGNOSES of President Trump. That is definitely in violation of the Goldwater Rule. Opinions are ok. Psychiatrists and other physicians are free to make their assessments from TV and radio and discussing them privately. But as Dr. Loh says, they should not proclaim these as professional opinions in a public forum.

I really enjoyed reading this article, as I think it raises some important points to consider.

1. Regarding your first pillar of Goldwater: assuming it’s true “no examination, no diagnosis”, any reasonable person might wonder, given the amount of publicly available evidence, that something is ‘wrong’ with Donald Trump. Doctors, as reasonable persons but more so because of their professions, might also think that something is ‘wrong’ with Donald Trump and may posit a diagnosis without examination. At that point, might it not be reasonable for doctors to suggest that that Trump ought to undergo an actual examination to, in fact, see if there’s a diagnosis to be made? This is intentionally a weaker conclusion than the one you address in your article, but I’m wondering if this would satisfy the Goldwater rule, in your opinion? If so, would this be in keeping with what is permissible for a doctor to do, under the guise of a doctor, in a public forum? (NB: If the answer to the first question is ‘yes’, it would also raise the specter that doctors not only have a permission, but also an obligation to publicly ask for Donald Trump to undergo a proper examination.)

2. Regarding your second pillar: as you yourself write, a diagnosis doesn’t imply incompetence. As such, it’s moot to assume that if those two presidents and the prime minister were diagnosis that their actions would have been deemed incompetent. It’s just that in the case of Trump, he’s incompetent (my belief) and we’re all searching for a cause(s).

3. In keeping with others on this thread, Trump may very well just be a “bad hombre” and not much else. Perhaps that’s the cause.

4. Under the 25th amendment, section 4, it just says that the VP has to demonstrate to congress that the president is “unable to discharge the powers and duties of his office” but doesn’t actually say what that means or how this is demonstrated. It’s a political decision and it doesn’t seem like you need a psych diagnosis. This is more so an FYI.

5. Re: pillar three: that’s a big, big can-of-worms and I’m not sure to what extent it’s even true (though, again, there may be versions of it that are true).

1. I think it’s fare for MDs to say “There’s something clearly wrong, he should undergo a formal assessment.” We do this many times with family members, e.g. “That might be a fracture – I think you should get it checked out.” – and that’s would be fine. Where I disagree is whether it obliges doctors to go public. Duty to warn typically applies in cases of threatened suicide or homicide, child abuse, or in defined legislative pieces such as ability to drive. Still, there isn’t anything from stopping MDs from publicly expressing their concern. However, in using their credentials in that manner, I would argue the concerns around potential partisan perceptions (e.g. Dr. Bandy Lee’s sessions have only ever been attended by Democrats) and the question still arises – why this one, why not others? (e.g. where were you when Chavez was around, or Mugabe, or etc.)

2. I would posit that the parallels of certain historical figures was not to negate the point I made around competence vs. mental health, but extending the argument that “Trump = harm” to its logical end – if we want to use a diagnosis to take on one leader, arguably this could have been also done with these historic figures with serious repercussions.

3. Indeed, and bad hombre is not a diagnosis – in an earlier version of this paper, I suggested Martin Shrekeli was similarly well disliked, but was never publicly diagnosed given his activities. Some suggest that this is falsely equivalent, but I think it’s a slippery slope once you start diagnosing public figures – where do you arbitrarily draw the line about “who’s dangerous and needs to be diagnosed” and “who isn’t?” Eventually, are we all up for grabs in the public sphere?

4. This is correct – decision is taken by Vice-President and Congress. A diagnosis is not required, though may be considered. Precedent suggests that this amendment was only invoked in the past in serious cases of incapacity.

5. Simply put, in our line of work as public health physicians, diagnosing a politician has never been a pre-requisite to objectively supporting or opposing the positions taken by those politicians.

This document is provided under the terms of a CreativeCommons Attribution Non-commercial Share Alike license. The terms of the license are available at: http://creativecommons.org/licenses/by-nc-sa/3.0/. Attributions are to be made to HealthyDebate.ca, a project under the direction of Dr. Andreas Laupacis, at the Keenan Research Centre, Li Ka Shing Knowledge Institute of St. Michael’s Hospital.